01-Eyehistory.Pdf

Ophthalmologist by Tim Root, M.D. A thorough eye exam is important! Not only is the eye the most important organ in the body (of course!), but many common systemic diseases show ocular involvement.In fact, some conditions, like diabetes, may be first detected with the eye exam. To help organize your eye exam, I’ve made a sample ophthalmology note on the facing page. Our clinic notes aredifficult to interpret as our physical exam is long, specific, and requires many abbreviations to fit on a single page. In many ways, it’s a combination of a neurology and a dermatology note. Here’s arundown of the basic ophthalmology note’s components. History of Present Illness: As with all other specialties, a detailed ocular history is crucial to diagnosis. You should explore everycomplaint with the “basic questions” -- when did it start, what’s it like, is there anything that makes it better or worse, are you taking any medications for relief, etc.. Specific HPI review of systemsshould also include these eye specific questions: • Floaters and flashing lights: These are the classic symptoms of a retinal detachment and retinal tears, so ask EVERY patient about these symptoms.Most patients complain of some floaters - see if they’re actually new or have worsened recently. • Transient vision loss: Think of migraine vessel spasm in the young and micro-emboli in the elderly.Curtains of darkness might indicate an ischemic event or a retinal detachment, so explore these symptoms in detail. • Blurry vision: Is the vision always blurry? Does it worsen when reading orwatching TV? People blink less when watching TV and develop dry eyes. Is this a glare problem at night that might indicate cataracts? Is this a patient with poor glycemic control with resultinghyperosmotic swelling of their lens? • Red, painful eyes: A common complaint. Be sure to ask about the nature of the pain (is this a scratchy pain, aching pain, or only pain with bright light). Is there...